Every finding on record at Whitehall of Deerfield

Based on observation, interview and record review the facility failed to ensure fall interventions were in place for a resident at high risk for falls for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 3.The findings include:R3's Fall Risk Evaluation dated 4/29/26 shows that she is at high risk for falls. R3's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and requires substantial/maximal assistance to sit to stand, transfer and walk.R3's Incident Report dated 4/29/26 shows, At 2:30 AM patient is sleeping comfortable in bed resting, and when medication pass was for her at around 5:15, nurse observed patient on the floor, head towards the foot of the bed.Resident unable to give description.R3's Fall Care Plan shows an intervention initiated on 5/6/26 for: Please keep high floor mats in place on both sides of bed as appropriate- date initiated 4/29/2026.On 5/6/26 at 11:10 AM, R3 was laying in bed. R3 did not have fall mats next to her bed or in her room. At 12:41 PM, R3 was sitting in bed with the head of her bed elevated. R3 now had fall mats in her room. The fall mat on the left side of her bed was on the floor but it was not parallel to the side of her bed. The fall mat for the right side of the bed was propped up against the wall and not near her bed. At 12:42 PM, V7 (Certified Nursing Assistant-CNA) entered the room to assist R3 with the noon meal. V7 said that he is not sure if R3 is supposed to have fall mats or not. V7 said that R3 did not have the fall mats in place earlier that day and this was the first time he saw floor mats in her room. On 5/6/26 at 11:23 AM, V3 (Care Plan Coordinator-Registered Nurse) said that R3's baseline is agitated and irritated. V3 said that R3 has been getting weaker and does not get out of bed much. V3 said that after R3's fall on 4/29/26, it was implemented to apply a fall mat to the sides of her bed and they should be down at all times when R3 is in bed. The facility's Fall Occurrence Policy shows, Those identified as high risk for falls will be provided fall interventions.The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. The Falls Coordinator will add the intervention in the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and wore and/or changed personal protective equipment (PPE) in a manner to prevent potential exposure to and transmission of contagious diseases. These failures have the potential to affect all 151 residents living in the facility.The findings include:The facility's Facility Data Sheet dated 1/20/26 shows their current census is 151.The facility's 1st Floor Census sheet dated 1/20/26 shows R2, R3, and R4 are each positive for COVID-19.The facility's Isolation Tracking sheet dated 1/19/26 shows R2 tested positive for COVID-19 on 1/14/26, R3 tested positive for COVID-19 on 1/17/26 and R4 tested positive for COVID-19 on 1/16/26. They were each placed on contact/droplet isolation on the day they tested positive.On 1/20/26 at 10:40 AM, V10, Certified Nursing Assistant (CNA), went to R2's room wearing a surgical mask. V10 then put a N95 mask over the surgical mask along with other PPE (gloves, face shield, and gown) and entered R2's room. R2's room was marked with a sign for N95 Plus Eye Protection and Contact Precautions.On 1/20/26 at 10:50 AM, V8, Physical Therapy Assistant (PTA) exited R3's room wearing a surgical mask over an N95 mask, he did not remove either mask and did not use hand sanitizer outside the room. On 1/20/26 at 10:52 AM, V8, wearing the same masks, went to R4's room. V8 said he is doing in room therapy with the COVID-19 positive residents. V8 said he knows what/if a resident is on isolation by looking at the sign on their door outside their room. R4's room was marked with a sign for N95 Plus Eye Protection and Contact Precautions. V8 said he can go to Covid rooms wearing the same N95 mask, then entered R4's room.On 1/20/26 at 10:51 AM, V10 went to R3's room which was marked with a sign for N95 Plus Eye Protection and Contact Precautions. V10 placed an N95 mask over her surgical mask (along with other required PPE), then entered R3's room.On 1/20/26 at 11:11 AM, V4 Infection Prevention Nurse, said residents with COVID-19 are placed on Contact/Droplet Isolation. The signs outside their rooms indicate the PPE to be worn in the rooms at all times. The required PPE for the Contact/Droplet Isolation rooms includes a gown, gloves, eye protection, and an N95 mask. V4 said N95 masks are to be changed after leaving every room, all PPE is thrown away and new PPE is donned before going into the next room. V4 said the N95 mask is fit tested to be worn and fitted to the person; a surgical mask with an N95 over it is not appropriate. V4 said it would not be effective coverage to protect against COVID-19 or influenza. V4 said hand hygiene needs to be done before entering and after leaving each resident room.On 1/20/26 at 1:46 PM, V4 said they try to keep staff in same unit, but they may have to work on other units.On 1/20/26 at 1:50 PM, V5, Director of Rehab, said staff wear an N95 mask, gowns, gloves, and eye protection/face shield when seeing COVID-19 residents. Staff must change all of their PPE and use hand sanitizer between residents. V5 said she tries to have the same staff see Covid patients to minimize exposure, but assignments may change daily.On 1/20/26 at 1:58 PM, V11, Regional Nurse, said they educate staff on donning/doffing PPE using the isolation poster. V11 said the isolation for COVID-19 is contact/droplet precautions.The facility's Infection Prevention and Control Policy (revised 2/10/25) shows hand hygiene will be performed by staff before and after direct patient contact and after each situation that necessitates hand hygiene.The facility's Infectious Diseases Isolation Guideline & Care Policy (updated 2/13/25) shows residents with COVID-19 are placed on contact, droplet, N95 precautions for 10 to 20 days depending on the degree of illness.The facility's N95 Plus Eye Protection and Contact Precautions sign (poster) (dated 1/25) shows everyone must clean their hands, including before entering and when leaving the room, put on a fit-tested N-95 respiratory mask before room entry, and remove it after exiting the room.

Based on observation, interview, and record review the facility failed to ensure facility recipes were followed. This has the potential to effect all residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid Services form 671 shows there are 131 residents residing in the facility. Facility provided list of residents that have an order of NPO (Nothing by Mouth) show there are three residents with an order of NPO that do not receive food from the kitchen. Facility provided menu week at a glance shows on 4/21/25 the noon meal includes beef barley soup, turkey and Swiss cheese sandwich, three bean salad, and mandarin oranges. 1. On 4/21/25 9:48 AM, dietary staff were seen scooping three bean salad from a bulk container into portion cups for the noon meal. The staff member was using a 4 ounce (oz) slotted spoodle with a green handle. On 4/21/25 at 11:20 AM, the mandarin orange portion in the portion cups being placed on resident trays appeared small. On 4/21/25 at 12:02 PM, V3 (Food Service Director) measured both the mandarin orange and three bean salad portion sizes provided on the trays at lunch. V3 used a slotted 4oz spoodle with a green handle to measure and both the mandarin orange portion and three bean salad portion did not fill the 4oz spoodle. V3 said the approximate portion sizes of the mandarin oranges was 2oz and the approximate portion of three bean salad was 3oz, respectively. V3 said the menu that is posted on the bulletin board in the kitchen does not indicate portion sizes and staff would have to ask V3 to get the recipe binder to review the correct portion sizes for each meal. Facility Diet Spreadsheet shows the correct serving utensil for both the three bean salad and mandarin oranges should be a #8 scoop, which provides 4oz. 2. On 4/21/25 at 12:18 PM, the facility provided test tray of both a regular meal and a puree meal included pureed soup. The pureed soup was in a coffee mug with a plastic lid. When the plastic lid was removed, a dark, beef broth-like liquid was revealed and was a thin-liquid consistency. On 4/21/25 at 12:10 PM, R76 was sitting up in his wheelchair in the hall outside of R76's room. R76's lunch tray was delivered and R76 tasted the brown colored thickened liquid in the mug on R76's tray. Loudly, and very upset, R76 proclaimed, This is not beef barley soup! Look at the menu, it's supposed to be beef barley soup! What is this? I'm not eating this! On 4/21/25 at 12:10 PM, V3 (Food Service Director) said the cook will remove a portion of the cooked soup for the day, strain the solids from the liquid, and serve the liquid in coffee mugs. Kitchen staff will provide a thickening packet on resident trays that have orders for thickened beverages and nursing staff will thicken the soup before delivery. On 4/23/25 at 9:09 AM, V1 (Administrator) said after talking with V3 and V18 (Clinical Nutrition Manager- Registered Dietitian) the proper process of making the pureed soup is taking a portion of the regular soup, including the liquid and solids, puree the mixture, then strain the pureed mixture through a strainer to ensure a smooth, uniform consistency that is free of chunks. Facility provided recipe for pureed beef barley soup, provided on 4/21/25, shows that it was redacted with white-out stating, Place prepared beef barley soup in [sic] strain to get a broth. Facility provided recipe for pureed beef barley soup, provided on 4/23/25 without white-out, states, Place prepared beef barley soup in food processor and blend to a smooth consistency.

Based on observation, interview, and record review the facility failed to ensure safe food handling procedures were being practiced. This has the potential to effect all residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid Services form 671 shows there are 131 residents residing in the facility. Facility provided list of residents that have an order of NPO (Nothing by Mouth) show there are three residents with an order of NPO that do not receive food from the kitchen. 1. On 4/21/25 at 9:53 AM, V4 (Dietary Aide) and V5 (Dietary Aide) were breaking down breakfast trays on one side of the dirty side of the dish machine counter. V6 (Dietary Aide) was wearing gloves and was placing plates, utensils, trays, and other items into dish racks and running them through the dish machine on the opposite side of the dish machine counter from V4 and V5. V6 went over to the clean and sanitized of the dish machine, moved dish racks out of the way to allow more dish racks to run through the dish machine, then went to the sink attached to the dirty side of the dish machine counter, rinsed his hands while still wearing the same gloves, returned to the clean and sanitized dish racks and removed a food service pan from the rack and placed it on the shelf above the counter. V6 returned to the dirty side of the dish machine and continued to load dish racks with the same gloves. On 4/21/25 at 11:39 AM, it was observed that there are no soap dispensers where V6 rinsed V6's gloved hands. On 4/21/25 at 11:52 AM, V3 (Food Service Director) said V3 prefers that kitchen staff do not wear gloves when washing dishes so the kitchen staff know when their hands become soiled and need to be washed. V3 said staff should remove their gloves and wash their hands after handling dirty dishes and before handling clean dishes. Facility Kitchen Policy dated 8/16/24 states, . e. Staff will was hands after handling soiled items, after using the toilet, after removing gloves, and after switching from working with raw food items to working with ready to eat food. 2. On 4/21/25 at 11:16 AM, V7 (Cook's Helper) removed a food service pan of mashed potatoes from the warmer. V7 grabbed a scoop that was sitting on top of the warmer atop a piece of aluminum foil, scooped out a portion of mashed potatoes, and placed the scoop back onto the warmer on the aluminum foil. The scoop was not covered. On 4/21/25 at 11:37 AM, V7 removed a food service pan of meat sauce from the warmer. V7 grabbed a scoop that was sitting in a clean food service pan on top of the warmer, scooped out a portion of meat sauce, and placed the scoop back into the food service pan on top of the warmer. The scoop was not covered. On 4/21/25 at 11:58 AM, V3 said the scoops should be covered to prevent cross contamination or V7 should have washed the scoops immediately after use. 3. On 4/21/25 at 11:49 AM, V22 (Cook) grabbed multiple soup base containers from a shelf below the prep counter and placed them onto the counter. V22 opened the soup containers, pulled out portion cups that were stored inside the soup base containers, and scooped some of the contents into a pot. V22 placed the portion cups back into the soup base containers, placed the lids back onto the soup base containers, and placed the containers back onto the shelf for storage. On 4/21/25 at 11:51 AM, V3 said the portion cups should not be stored inside the soup base containers and V22 should have removed them. Facility Food Handling Policy, dated 7/26/24 states, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

Based on observation, interview and record review the facility failed to ensure insulin pens and tuberculin purified protein derivative (PPD) were labeled with open and with expiration dates, and failed to ensure medications were stored securely for 5 of 10 residents ( R78, R16, R384, R385 and R386) reviewed for medication labeling/storage in the sample of 27. The findings include: On [DATE] at 11:03 AM, in the 2nd floor medication cart there were 2 insulin pens open that were not dated and 1 insulin pen that had expired on [DATE]. These were identified as flextouch insulin pens belonging to R78 which included one expired pen and one unlabeled pen, and a unlabeled Humalog kwik pen belonging to R16. At 11:03 AM while checking the medication cart V10 (Registered Nurse/ RN) said insulin pens should be labeled when they are opened and have the expiration date also, which would be 28 days later. V10 said all expired pens or medications should be immediately removed from the medication cart and disposed of. On [DATE] at 11:18 AM, while the surveyor was checking a second medication cart with V11 (Licensed Practical Nurse/LPN), V10 showed the surveyor that she had put dates on the insulin pens and was going to put them back inside the medication cart. The surveyor asked how she determined when the pens were opened as one of the pens was dated for [DATE]. V10 then placed the insulin pens on the top of her medication cart and walked down to the medication room leaving the pens unsecured and sitting out. At 11:25 AM the insulin pens were still sitting on the top of the medication cart. R16's Medication Administration Record (MAR) shows he has an order with a start date of [DATE] for a Humalog kwik pen which is being administered twice a day. R78's MAR shows he has an order for Tresiba Flex touch injector-pen which is given once a day. On [DATE] at 11:38 AM, the 2 North medication room was observed with the surveyor and V13 (RN) inside the refrigerator were 2 open not dated Tuberculin PPD solution vials, one was half full and the second a quarter full. V13 said those are used when new admission come in to 2 North and they administer the vials to do TB skin tests. V13 said the vials should be dated when open and he thinks they are good for 30 days. When the surveyor asked V13 how he would know that the vials are still good if there is no date to identify when it was opened he replied good point. V13 said a couple residents just had TB tests from the vial a couple days ago. V13 then placed both vials back in the refrigerator and locked it. The facility provided a list of residents recently admitted to 2 North which included R385 and R386 both were admitted on [DATE], and R384 who was admitted on [DATE]. R384's MAR shows he received 2 doses of Tuberculin PPD on [DATE] and [DATE]. R385 and R386's MAR's show they both received doses of the Tuberculin PPD on [DATE]. On [DATE] at 9:58 AM, V2 (Director of Nursing) said insulin pens and Tuberculin solution should all be dated when opened and have an expiration date on them. V2 said tuberculin solution and most insulin pens are good for 28 days but they follow pharmacy recommendation guidance for the expiration dates. V2 said expired medication should be immediately removed from the medication carts and all medication should be secured and not left sitting out on the top of medication carts. The facility provided Medication pass policy last revised [DATE] shows all opened medication vials should be labeled with the date opened and expires in 28 with the exception of one insulin and an eye drop medication. The facility provided Medication, Storage, Labeling and Disposal policy last revised on [DATE] shows that medication will be secured in a locked storage area and medications should be labeled with the name of the medication, and the expiration date.

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for five of 27 residents (R30, R51, R383, R382, R376) reviewed for infection control in the sample of 27. The findings include: 1. R30's Admission Record dated April 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dysphagia, osteomyelitis, cognitive communication deficit, pressure injury of sacral region, and attention to gastrostomy (Percutaneous endoscopic gastrostomy tube/feeding tube/G tube). R30's Order Summary Report shows she has an indwelling catheter drainage bag and has a wound dressing change to her sacrum. R30's orders do not include an order for enhanced barrier precautions. R30's Care Plan initiated on February 20, 2025 shows, [R30] is on enhanced barrier precaution related to g-tube. On April 22, 2025 at 11:20 AM, R30 was observed in her bed. R30 tube feeding was infusing. There was a urinary drainage bag noted to R30's right side of her bed. There was no enhanced barrier precaution sign outside of R30's door, nor was there a cart with personal protective equipment. On April 23, 2025 at 9:13 AM, V2 Director of Nursing (DON) said R30 should be on enhance barrier precautions. V2 said there should be a sign outside of R30's door, and there should be a cart with personal protective equipment outside of her room. 2. R51's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, pneumonitis, difficulty in walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder. On April 21, 2025 at 1:23 PM, V20 Certified Nursing Assistant (CNA) provided incontinence care to R51. V20 folded R51's incontinence brief in between R51's legs from the front. V20 wiped R51's front peri area. There was urine in R51's incontinence brief. R51 then helped R51 to turn onto his right side by touching R51's body. V20 then wiped a stool smear from R51's buttocks. V20 then retrieved a new clean incontinence brief placed it under R51 then help R51 turn back onto his back. V20 applied the clean incontinence brief, replaced R51's clean shorts, placed a pillow in between R51's legs, and applied R51's protective heel boots. V20 did not change his gloves or perform hand hygiene when going from dirty to clean items. On April 23, 2025 at 9:13 AM, V2 DON said hand hygiene should be performed and gloves should be changed after removing dirty items and before touching clean items. 47552 3. R382's Facesheet shows R382 was admitted to the facility on [DATE]. R382's Risk Evaluation for Isolation form dated 4/12/25 shows R382 has an indwelling catheter and should be on enhanced barrier precautions (EBP) until the device is discontinued. R382's Order Summary Report dated 4/22/25 does not have orders for R382 to be on EBP. On 4/22/25 at 9:31 AM, R382's was lying in bed with the indwelling catheter tubing and collection bag hanging from R382's bed. On the wall next to R382's entrance door, no EBP signage was posted indicating R382 was on EBP and there was no personal protective equipment (PPE) cart outside of R382's room. On 4/23/25 at 10:36 AM, R382's door still did not have any EBP signage and there was no PPE cart outside of R382's room. 4. R376's Facesheet shows R378 was admitted to the facility on [DATE]. R376's Risk Evaluation for Isolation form dated 4/19/25 states R376 does not have any indwelling medical devices. R376's Admission Progress Note dated 4/18/25 states, . Resident has a foley (indwelling catheter) that was placed on 4/16/25 . R376's Order Summary Report dated 4/22/25 does not have orders for R376 to be on EBP. On 4/21/25 at 10:27 AM, R376 was sitting in R376's wheelchair with an indwelling catheter tube running to a collection bag hanging from R376's bed. On the wall next to R376's entrance door, no EBP signage was posted indicating R376 was on EBP and there was no PPE cart outside of R376's room. R376 said staff would wear gloves when providing care to R376 but staff were not wearing gowns. On 4/23/25 at 10:35 AM, on the wall next to R376's entrance door, an EBP sign was posted indicating R376 was on EBP and there was a PPE cart outside of R376's room. 5. R383's Facesheet dated 4/22/25 shows R383 originally admitted to the facility on [DATE]. R383's Risk Evaluation for Isolation form dated 4/22/25 shows R383 has an IR (Interventional Radiology) drain and should be placed on EBP until the device is discontinued. R383's Order Summary Report dated 4/22/25 does not have orders for R383 to be on EBP. On 4/22/25 at 9:26 AM, R383 was lying in bed with a drainage tube running into a collection bag that was hanging from R383's bed. On the wall next to R383's entrance door, no EBP signage was posted indicating R383 was on EBP and there was no PPE cart outside of R383's room. On 4/23/25 at 10:34 AM, on the wall next to R383's entrance door, an EBP sign was posted indicating R383 was on EBP and there was a PPE cart outside of R383's room. On 4/23/25 at 9:16 AM, V2 (Director of Nursing) said the Risk Evaluation for Isolation form is completed by the admitting nurse at the time of an admission. The form is conducted to assess whether a resident may need any isolation procedures. If the resident has an indwelling medical device, the resident should be placed onto EBP. V2 said examples of indwelling medical devices include, but are not limited to, PICC (peripherally inserted central catheter) lines, midline catheters, foley (indwelling) catheters, IR drains, gastrostomy tubes, and PEG (percutaneous endoscopic gastrostomy) tubes. V2 said if a resident is placed on EBP, there should be a sign indicating they are on EBP and a PPE cart will be placed outside of the resident's door. V2 said both the sign and cart can and should be applied as soon as possible once it is determined EBP is needed. The facility's Gloves Usage policy revised on March 23, 2023 shows, If the resident needs EBP, the facility will provide care following the EBP policy. A transmission based precaution set up will be provided outside the resident's room to provide personal protective equipment like gown and gloves to staff including contracted workers and visitor entering the residents' room. A sign will be provided outside the room for resident on transmission based precaution indicating the type of the precaution (contact, droplet, or EBP). Hand hygiene will be performed by staff and contracted workers before and after direct patient contact and after each situation that necessitates hand hygiene. The facility's Enhanced Barrier Precaution policy revised on July 26, 2024 shows, The facility will use EBP to reduce transmission of multi-drug resistant organisms in the nurse homes. EBP involves the use of gowns and glove to reduce transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with multi-drug-resistant organisms as wall as residents with wounds and/or indwelling medical devices. EBP will be used for any resident in the facility with open wounds and/or has indwelling medical devices including central line, urinary catheter, feeding tubes.

Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner for one of 27 residents (R51) reviewed for dignity in the sample of 27. The findings include: R51's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, pneumonitis, difficulty in walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder. On April 21, 2025 at 12:17 PM during the lunch meal, R51 was sitting in his high back recliner. V21 Activity Coordinator was standing in front of R51 spooning thickened liquids and pureed food into R51's mouth. V21 was not sitting down within eye to eye level of R51. On April 23, 2025 at 9:13 AM, V1 Administrator said staff should be sitting down while feeding residents so they are able to engage with the residents. V1 said an inservice was provided to staff in regards to sitting while feeding residents. The facility's Privacy and Dignity Policy revised August 16, 2024 shows, It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observation, interview, and record review the facility failed to monitor weights for a resident with weight loss and failed to apply compression stockings for a resident with a history of blood clots which applies to 2 of 2 residents (R96, R5) reviewed for quality of care in a sample of 27. The findings include: 1. R96's Facesheet printed on 4/23/25 showed R96 is an eighty-three year old female resident readmitted to the facility from a hospital stay on 3/24/25 with diagnoses which included: Parkinson's disease, acute post hemorrhagic anemia, stage 3 sacral pressure ulcer, dysphagia, mild protein-calorie malnutrition, and malignant neoplasm of pancreas. R96's medical record showed a readmission weight of 160 pounds on 3/24/25. R96's previous weight of 2/8/25 was 171 pounds. This is a 6.4% difference. On 4/21/25 R96's weights were reviewed. These were the only 2 weights in R96's vitals section. R96's Order Summary Report printed on 4/22/25 showed an order for weekly weights to be done every Monday. The order start date is 3/24/25. On 4/22/25 at 1:46 PM, V18 Clinical Nutrition Manager (Dietitian) stated R96 has multiple issues which could cause weight loss. Weight need to be done to monitor a resident for weight loss. If you do not know a resident is losing weight you will not know to do anything about it. Orders should be done as ordered which is usually daily, weekly, or monthly. The facility's Weights Policy revised on 8/19/24 showed weights should be obtained monthly unless otherwise ordered differently by the physician. 35119 2. On 4/21/25 at 1:23 PM, R5 was brought to her room from the dining room. R5 was assisted to bed for incontinence care. R5 did not have compression stockings on her legs. On 4/22/25 at 2:17 PM, R5 was in bed in her room. V11 Licensed Practical Nurse (LPN), with this surveyor, lowered R5's blankets and lifted R5's pant legs. R5 did not have compression stockings on her legs. V11 said she was not sure if R5 wears stockings or not. On 4/23/25 at 9:09 AM, V2 Director of Nursing said the expectation is to follow all physician orders including treatments, medications, and compression hose. R5's Physician Orders dated 11/13/23 shows, Apply bilateral knee high stockings in the AM and remove at HS. R5's Physician Progress Note dated 3/14/25 shows, Right lower extremity deep vein thrombosis status post Inferior Vena Cava filter, apply bilateral knee high stockings in AM and remove at HS.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for residents at risk for developing pressure injuries for three of six residents (R276, R26, R51) reviewed for pressure injuries in a sample of 27. The findings include: 1. R276's Facesheet printed on 4/22/25 showed R276 is an eighty-five year old male resident admitted to the facility on [DATE] with diagnoses which include: type 2 diabetes mellitus, peripheral vascular disease, unstageable sacral pressure ulcer, and needing assistance with personal care. R276's Braden Skin Assessment summary printed on 4/23/25 showed R276 has been at High Risk for developing pressure injuries since his initial assessment on 4/10/25. On 4/21/25 at 11:20 AM and 1:20 PM R276 was lying in with his legs/heels directly on the mattress. On 4/22/25 at 9:50 AM R276 was in the same possition with no heel offloading devices in place. R276's legs had reddened areas along the calf area. R276 stated the reddened areas were abrasions sustained from a fall prior to being admitted . R276 stated it had been a while since the staff had offered to have anything placed under his legs. On 4/22/25 at 2:20 PM, V19 (R276 family) stated they had not been told R276 had ever refused to have his feet offloaded while in bed. On 4/23/25 at 10:00 AM V15 Wound Nurse Manager stated off loading heels is a preventative intervention for pressure injuries. If a resident refuses an intervention they should be reapproached later to attempt to put the intervention in place. on 4/23/25 at 10:15 AM V17 Scheduler/Certified Nursing Assistant (CNA) stated the devices we use for heel protection and off-loading are our green boots (padded) and pillows which are placed under a residents heels/legs to relieve the pressure on the heels. If a resident refuses cares or repositioning (includes off-loading) we need to reapproach the resident to try again. R276's Careplan printed on 4/22/25 showed R276 having a focus for poor skin integrity and having a pressure injury with an intervention of off-loading R276's heels when in bed. 35119 2. On 04/21/25 at 12:46 PM, V20 Certified Nursing Assistant (CNA) wheeled R26 from the lunch room to her room. R26 had a padded heel boot on her right left only. V20 said R26 does not have any wounds on her heels, the boots are for protection. R26's Physician Orders dated 12/4/23 shows an order heel suspension boots when in bed or up in the wheelchair every shift. On 04/23/25 at 10:18 AM, V15 Wound Nurse Manager said R26 has an arterial wound on her right great toe. V15 said R26 likes to her cross legs which impairs her circulation, so the heel boots reduce pressure and to prevent new wounds. V15 said if R26 is refusing the heel boots, staff should let the nurse know and chart the refusal. R26's Treatment Administration Record shows on 4/21/25 heel suspension boots were applied, there is no documentation of refusal. On 04/23/25 at 9:09 AM, V2 Director of Nursing said the expectation is to follow all physician orders including treatments, medications, and pressue reducing boots. 34506 3. R51's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, pneumonitis, difficulty in walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder. R51's Risk assessment dated [DATE] shows he is at a high risk for developing pressure injuries. R51's Care Plan intitiated November 29, 2024 shows, [R51] is at risk for impairment to skin integrity due to disease process, diagnosis of Parkinson's Disease with fluctuation, decreased mobility, incontinence of bowel and bladder, and fragile skin. Off load heels. On April 21, 2025 at 10:48 AM, R51 was sitting in the facility's dining room in a high back wheeled recliner. R51's heels and feet were on the recliners foot rest. On April 22, 2025 at 11:13 AM, R51 was sitting in his high back wheeled recliner. There was no pillow or protective heel boots. R51's feet and heels were directly on the foot rest of the high back wheeled recliner. On April 23, 2025 at 9:13 AM, V2 Director of Nursing (DON) said resident's heels should be offloaded. Residents' heels should be elevated and can be offloaded with pillows or heel protective boots. The facility's Wound Care Guidelines Policy reviewed January 24, 2024 shows, Residents may be properly positioned in bed using pillows or other supportive devices to help protect bony prominence areas susceptible to pressure. Offload elbows and heels as needed. Elevate resident heels off the bed as indicated.

Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent a contracture from getting worse for one of 27 residents (R69) reviewed for range of motion in the sample of 27. The findings include: R69's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, dysphagia, and pressure injury of sacral region. R69's facility obtained picture shows that R69 had a rolled wash cloth to his left contracted hand. On April 21, 2025 at 10:08 AM, 10:52 AM, and 1:11 PM R69's left hand was contracted and bent up on his chest. There were no devices in place to R69's contracted hand. On April 23, 2025 at 9:13 AM, V2 Director of Nursing (DON) said R69 should have a rolled washcloth in place to his contracted hand. V2 said the rolled wash cloth is used to help prevent further injury to his left hand. The facility's Restorative Nursing Program revised August 19, 2024 shows, Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Nursing and Restorative Services may include the following: Contracture Prevention and Management: passive range of motion, active range of motion, and splint/orthotic management.

Based on observation, interview, and record review the facility failed to ensure medications were administered according to professional standards. This applies to 1 of 27 residents (R380) reviewed for pharmacy services in the sample of 27. The findings include: On 4/22/25 at 9:02 AM, R380 was lying in bed watching television. On R380's bedside table on the right side of R380's bed there was a small plastic cup that contained two pills. R380 said the pills were mycophenolate and R380 has to take them on an empty stomach. R380 said she did not eat breakfast until almost 9:00 AM on 4/22/25 and was holding them to take around 9:30 AM. R380's Order Summary Report dated 4/23/25 shows R380 has an order for mycophenolate, take two tablets by mouth one time a day for organ transplant. R380's Order Summary Report does not show R380 has orders to self-administer medications. On 4/23/25 at 9:13 AM, V2 (Director of Nursing) said the normal procedure of providing a resident medications includes introducing themselves to the resident, answering any questions about the medications that the resident may have, and provide the resident with the medication. If a resident does not want to take the medication at that time, the nurse is to take the medication with them and not leave the medication in the room with the resident. V2 said there are no known residents at this time in the facility that are able to self-administer medications. Facility Medication Pass policy dated 8/16/24 states, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on interview and record review the facility failed to administer a pneumococcal vaccine to 1 of 5 residents (R26) reviewed for immunizations in the sample of 27. The findings include: R26's face sheet shows she was admitted to the facility on [DATE]. R26's Immunization Report shows she was administered a Pneumococcal Conjugate Vaccine 13 (PCV13) on 10/20/18. There are no additional documented Pneumococcal vaccines in R26's Immunization report or any documented refusals of Pneumococcal vaccines in her Electronic Medical Record. On 4/23/25 at 12:22 PM, V14 (Assistant Director Of Nursing) said R26's second dose of her Pneumococcal vaccine a Pneumococcal Polysaccharide Vaccination 23 (PPSV23) should have been administered 1 year after her dose given on 10/20/18 but it was missed. The facility provided Pneumococcal Vaccination Policy last revised on 9/16/24 shows after receiving a PCV13 a person over age 65 should also receive a PPSV23 1 year after the PCV 13, or they could receive newer option (added after 2019) a PCV20. The policy also shows the facility should screen residents and administer Pneumococcal vaccinations as recommended by the CDC.

Based on the interview and record review, the facility failed to ensure that a resident's caregiver immediately reported a new injury of unknown origin for 1 of 1 residents (R1), who were reviewed for injuries of unknown origin in the sample of 4. The findings include: R1's current care plan showed that R1 was nonverbal, severely cognitively impaired, completely dependent on staff for all care, and unable to move her lower extremities without staff assistance due to her diagnosis of senile degeneration of the brain. A progress note for R1, dated 12/9/24, showed, Writer was notified by caregiver of bruise on left big toe, slightly swollen . Per caregiver, weekend caregiver identified the incident but did not report to the nurse on duty at the time . ordered X-ray of left foot. Site slightly warm to touch, no grimacing or pain elicited upon site palpation . R1's left foot X-ray report dated 12/10/24 showed results of acute intra-articular corner fracture at the lateral margin of the left great toe . R1's bruise/injury of unknown origin report showed R1 was unable to state what happened to her left toe due to her poor cognition. The report showed R1's power of attorney elected to not send R1 to the hospital for the injury but to have R1 remain in the facility and follow-up with R1's podiatrist. On 12/18/24 at 9:09 AM, R1 was seated in a wheelchair in her room as V3 (agency caregiver) fed R1 breakfast. This surveyor attempted to ask R1 questions but received no verbal response from R1. No spontaneous movement of R1's upper or lower extremities was noted. V3 stated R1 has a caregiver, hired by R1's family, assigned to her 7 days a week, from 8 AM-4 PM. V3 stated caregivers help facility staff provide cares to R1 but their role is primarily to provide companionship to R1 in the facility. V3 stated she alerted facility staff to R1's left toe injury on 12/9/24 as she found R1's great toe to be bruised and swollen. V3 stated, Her weekend caregiver (V18) actually noticed the bruising the day before (12/8/24) but I guess didn't tell any staff (facility) . V3 removed R1's sock on her left foot. Old, faded bruising was noted to the area between R1's left great toe and second toe. No redness, swelling, or wounds were noted to R1's left foot. On 12/18/24 at 1:38 PM, V18 (agency caregiver) stated she was assigned to R1 on 12/8/24, from 8 AM-4 PM V18 stated when she got R1 dressed that morning, she noticed R1's left great toe was bruised and swollen. V18 stated she never reported her findings to any facility staff on 12/8/24. V18 also stated she did not report R1's toe injury to her staffing agency until 12/9/24. V18 stated, I should have reported it immediately. I just assumed everyone knew about it . On 12/18/24 at 11:53 AM, V1 (Administrator) stated any resident caregiver, hired by a family to provide services to residents in the facility, are held to the same standards and expectations as our employees. V1 stated, We treat them (caregivers) as our employees. We do background checks on them as soon as we know they are going to be with our residents. Our concierge then reviews the private duty guidelines packet with the caregiver which the caregiver signs. In the packet, it specifically says the caregiver will follow the same rules as our staff which includes reporting abuse and/or injuries of unknown origin. (V3 agency caregiver for R1) reported (R1's) injury to us on that Monday (12/9/24). V18 (agency caregiver for R1) should have reported (R1's) injury immediately to a nurse when she found it on that Sunday (12/8/24) . On 12/18/24 at 2:00 PM, V2 (Director of Nursing) stated any resident caregivers that provide services in the facility are expected to follow the facility's abuse policy and report injuries of unknown origin immediately to a facility nurse. On 12/18/24 at 12:09 PM, V6 (Agency Supervisor of V18) stated V18 (agency caregiver of R1) should have reported R1's injury to the facility and the agency immediately on 12/8/24. The facility's Private Duty Guidelines orientation packet (undated) showed, While the patient is under our care it is your responsibility to cooperate fully with the policies and guidelines of this facility to maintain our high standards of care .Private duty personnel will follow the same rules of (facility) that all staff is required to follow . All accidents, loss of personal property or irregular occurrences must be reported to the charge nurse immediately . A change in the resident's condition should be immediately reported to the charge nurse . The facility's Abuse and Neglect policy dated 7/12/24 showed, Injuries of Unknown Origin are injuries that meets all 3 criteria . a) The source of the injury was not observed by any person; and b) The source of the injury could not be explained by the resident; and c) The injury is suspicious because of the extent of the injury or the location of the injury . All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee .

Based on interview and record review the facility failed to provide cares to a resident in manner that prevented a resident injury. The facility failed to ensure a resident was transferred via mechanical lift in a safe manner. These failures apply to 1 of 4 residents reviewed for safety and supervision in the sample of 4. The findings include: R1's current care plan showed R1 was nonverbal, severely cognitively impaired, completely dependent on staff for all cares, and unable to move her lower extremities without staff assistance due to her diagnosis of senile degeneration of the brain. A progress note for R1, dated 12/9/24, showed, Writer was notified by caregiver of bruise on left big toe, slightly swollen . ordered X-ray of left foot. Site slightly warm to touch, no grimacing or pain elicited upon site palpation . R1's left foot X-ray report dated 12/10/24 showed results of acute intra-articular corner fracture at the lateral margin of the left great toe . R1's bruise/injury of unknown origin report showed R1 was unable to state what happened to her left toe due to her poor cognition. The report showed R1's power of attorney elected to not send R1 to the hospital for the injury but to have R1 remain in the facility and follow-up with R1's podiatrist. On 12/18/24 at 1:38 PM, V18 (agency caregiver) stated she was assigned to R1 on 12/8/24 (Sunday), from 8 AM-4PM. V18 stated when she got R1 dressed that morning, she noticed R1's left great toe was bruised and swollen. V18 stated she had received no report of R1 sustaining any falls or injuries prior to her shift. She had also received no reports of bruising or injuries to R1's left foot. On 12/18/24 at 12:32 PM, V17 (agency caregiver) stated she was assigned to R1 on 12/7/24 (Saturday), from 8 AM-4 PM. V17 stated she did not see any injuries to R1's left foot on 12/7/24. The facility's nursing schedule dated Saturday, December 7, 2024, showed the following staff provided cares to R1 on 12/7/24: a) V13 (Registered Nurse/RN) from 7 AM-3PM b) V14 (Nurse) from 11 PM-7 AM c) V12 (Certified Nursing Assistant/CNA) from 3 PM-7 AM On 12/18/24 at 12:55 PM, V13 (RN) stated she did not see any injuries to R1's left foot on 12/7/24. V13 stated R1 did not appear to be in pain on 12/7/24. V13 stated R1 had no falls and/or sustained no injuries on 12/7/24 that she was aware of. On 12/18/24 at 10:55 AM, V14 (Nurse) stated, (R1) was in bed for my shift but she did not appear to be in pain. I didn't see her feet because they were covered. I received no report of her having any recent falls or injuries . On 12/18/24 at 2:17 PM, V12 (CNA) stated she worked a double on 12/7/24; providing cares to R1 from 3 PM-7 AM. V12 stated she did not see any bruising, swelling or injuries to R1's left foot at any time during her shift. V12 stated, I don't know what happened to her foot. I used the hoyer (mechanical) lift by myself, after dinner, to put her to bed. No one was with me. I know I am not supposed to transfer her using the hoyer by myself but no one was available to help me. She didn't hit her feet at all when I transferred her . V12 stated she also provided incontinence care, twice, to R1 during her shift. V12 stated, I didn't see any injuries to her feet when I changed her either. On 12/18/24 at 11:37 AM, V5 (R1's Physician) stated, (R1) does have history of osteomyelities to her foot which could potentially make it easier to fracture but none the less, her injury was most likely caused by some type of blunt force trauma. On 12/18/24 at 2:00 PM, V2 (Director of Nursing) stated all (resident) mechanical lift transfers are to be completed with two staff members present to ensure a safe resident transfer. The facility's Mechanical Lift Transfers policy dated 8/16/24 showed, There will always be 2 staff present to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface .

Based on interview and record review the facility did not inform/invite a resident's representative to a care plan meeting for 1 of 3 residents (R1) reviewed for care plans in the sample of 3. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] and V8 (R1's Mother) was R1's guardian. The same document showed R1 was diagnosed with lack of expected normal physiological development in childhood and autistic disorder. On 12/2/24 at 11:15 AM, V8 said she was R1's Power of Attorney and had not been informed by the facility of a care plan meeting, care planning process, or attended any care plan meeting/conference. On 12/3/24 at 11:03 AM, V7 (Director of Social Services) was asked when R1's care plan meeting was. V7 did not give an exact date and said R1's care plan meeting took place throughout his stay at the facility. V7 said residents and their representatives are verbally informed when care plan meetings are scheduled. On 12/3/24 at 11:20 AM, V2 (Director of Nursing) said families and residents are verbally notified of care plan meetings. V2 added there may be documentation in the resident's progress notes that the resident/family have been informed of the care plan meetings. On 12/3/24 at 11:55 AM, there was no progress notes in R1's electronic medical record indicating V8 was informed of a care plan meeting. R1's progress note dated 11/7/24 showed the initial plan of care was reviewed with R1 and V8. The same progress note showed V8 was R1's Power of Attorney. R1's Baseline Care Plan Conference/Care Plan Summary document dated for 11/25/24 had two attendees signatures on the form. The signatures did not match R1's Consent for Psychotropic Medication Use document signed by V8. On 12/3/24 at 12:03 PM, V7 reviewed R1's Baseline Care Plan Conference/Care Plan Summary form dated 11/25/24 and said that form is filled out when there is a care plan meeting. The facility was unable to provide a care plan meeting policy.

Based on observation, interview, and record review the facility failed to change gloves while using the dishwasher and failed to sanitize food thermometers in a manner to prevent cross contamination. This applies to all residents residing in the facility. The findings include: The CMS 671 form dated 5/28/24 showed 139 residents residing in the facility. 1. On 5/28/24 at 10:31 AM, V14 (Dietary Aide) was wearing gloves while loading dirty dishes into the dishwasher. V14 wore the same gloves to dip a test strip into the 3-compartment sink. V14 returned to the dishwasher and continued loading dirty dishes. V14 was observed repeatedly loading and unloading dishes while wearing the same contaminated gloves. On 5/29/24 at 1:47 PM, V12 (Dietary Manager) stated dirty dishes should be rinsed and loaded into the dishwasher by one person then another person puts the clean items away. If the same person is loading and unloading, they need to change gloves or wash their hands in between. It prevents the dishes from getting dirty. The items can get contaminated with bacteria. Staff need clean hands and clean gloves whenever they are touching food and other surfaces. The facilities undated Cleaning Dishes/Dish Machine policy states: 2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes. 2. On 5/28/24 at 10:45 AM, V13 (Cook) took temperatures of the food items on the steam table. V13 pulled a metal-type thermometer out of the holder and stuck it into the pureed pork. V13 used a brown paper towel to wipe it off between each food he was testing, including pulled pork, pureed vegetables, mashed potatoes, and soup. A second reading was required for the pureed pork, vegetables, and potatoes. V13 used the same thermometer to test the foods but ran it under the water before using it. At 11:19 AM, V15 (Cook) tested the temperature of the baked chicken. V15 wiped the thermometer off with a brown paper towel, once after using it. V13 and V15 did not sanitize the thermometers before, during or after use. On 5/29/24 at 1:50 PM, V12 (Dietary Manager) stated food thermometers need to be cleaned before using them. Wiping it down with a paper towel is fine. We don't use anything special, but it should be sanitized prior to use. At least wash it between foods to be sure it is clean. The facility's undated Taking Accurate Temperatures policy states: 1. To take temperatures, a clean, rinsed, sanitized, and air-dried thermometer that is the metal stem type .is needed. **Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish washer or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (Use a new swab for each sanitizing.)

Based on observation, interview, and record review the facility failed to ensure residents followed smoking contracts for 2 of 2 residents (R24 & R27) reviewed for safety, supervision, and smoking in the sample of 28. The findings include: 1. On 5/30/24 at 10:18 AM, R27 was in a covered area, outside, sitting in a wheelchair wearing gray sweats, black tennis shoes and a hat. R27 did not have a smoking apron on. V4 (Life Enrichment Director) was standing outside observing R27 while she was smoking. V4 stated the smoking schedule was on the arm pad of R27's wheelchair. R27 moved her arm, and it showed the smoking times were 10:00 AM, 1:30 PM, and 4:15 PM. R27 stated she keeps her cigarettes in the bottom drawer in her room. V4 stated the nurse keeps R27's lighter. V4 stated R27 is supposed to wear a smoking apron and should have one on. R27 stated she would wear a smoking apron. R27 stated she has not refused to wear a smoking apron. The Smoking Contract dated 3/21/24 for R27 showed, if facility determines that the undersigned requires supervision, all tobacco products and lighters shall be held by nursing staff when not in use. Resident/patient who intends to smoke has been made aware that when smoking he/she must wear a protective apron, which can be obtained at any nurse's station throughout the building. The Care Plan dated 4/2/24 for R27 showed, the resident is a smoker and expresses desire to smoke at this facility. Provide a copy of the facility safe-smoking policy and explain the policy so the resident is fully aware of all obligations and the consequences of violating the rules. Require the resident's signature on the policy or a safety contract, as appropriate. Remind the resident that staff will be observing and supervising smoking related behavior. Non-compliance is to be documented in the medical record. The Progress Notes on 5/30/24 did not show any documentation on non-compliance with the smoking contract. The Face Sheet dated 5/30/24 for R27 showed medical diagnoses including dementia without behavioral disturbance, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, hyperlipidemia, gastro-esophageal reflux disease, and osteoarthritis. The MDS (Minimum Data Set) dated 3/22/24 showed a BIMS (brief interview for mental status) score of 14, no cognitive impairment. The facility's Smoking Policy (7/28/23) showed, Residents that do not abide by the facility's smoking policy will be re-educated about safe smoking practices. Facility may keep the resident's smoking materials when not being used by the resident. Those who are assessed as unsafe smokers will be provided supervision during smoking. 2. On 5/29/24 at 9:27 AM, R24 dressed with a sling on her right arm and propelling herself into her room in her wheelchair. R24 stated she is a smoker and goes outside to the covered area to smoke. R24 stated she goes out and smokes alone and does not have any designated time to smoke. R24 stated her smoking materials are kept by the nurse and she just asks for them when she goes outside to smoke. On 5/30/24 at 10:26 AM, R24 was sitting in her room in her wheelchair. R24 stated she can go outside to smoke whenever she wanted, doesn't have to have anyone with her, and has to get smoking materials from the nurse. R24 stated she has never worn a smoking apron. V9 (Registered Nurse) was outside of R24's room and stated she was R24's nurse for the day. V9 stated that she doesn't give R24 a smoking apron and that the facility does not have them. On 5/30/24 at 12:05 PM, V1 (Adminstrator) stated the facility has smoking aprons available. The Admit/Readmit Follow Up Note dated 5/10/24 for R24 showed she has dementia; she is alert and oriented 1-2 (person & time); forgetful. Requires frequent reorientation to reality and redirection by staff. Fall precautions observed at all times. The Smoking Contract dated 5/8/24 for R24 showed, a resident who intends to smoke has been made aware that they have to wear a smoking apron. The Smoking assessment dated [DATE] for R24 showed poor judgement or decision making skills are present. The assessment showed R24 is considered a safe smoker and may use/access smoking materials consistent with the facility policy. Staff is not required to remain in attendance while resident is smoking. Resident agrees to follow smoking rules. The Care Plan dated 5/16/24 for R24 showed, the resident is a smoker and expresses the desire to smoke at this facility. The resident is aware of the following rules and his/her responsibility to fully abide by these rules. The Care Plan Note dated 5/28/24 for R24 showed, R24 is status post hospitalization due to a fall at her memory care facility. R24 was diagnosed and treated for a right shoulder fracture and dislocation. R24 shows decreased safety awareness and her level of assist needed fluctuates. She is recommended assist with activities of daily living when she discharges. Discharge planner present to review discharge date .as well as recommendation for 24-hour supervision upon discharge. The Face Sheet dated 5/30/24 for R24 showed medical diagnoses including chronic obstructive pulmonary disease, centrilobular emphysema, metabolic encephalopathy, atrial fibrillation, peripheral vascular disease, aortic valve stenosis, right shoulder dislocation, and right humerus fracture.

Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter tubing was not laying or dragging on the floor for 1 of 3 residents (R434) reviewed for indwelling urinary catheters in the sample of 28. The findings include: On 5/28/24 at 11:48 AM, R434 was sitting in a high back wheelchair in the common area of the dining room. R434 had an indwelling urinary catheter, and the tubing was laying on the floor. R434 was propelling his wheelchair back and forth and the tubing was dragging on the ground. At 11:56 AM, V5 (Registered Nurse) pushed R434 to the dining room table with his catheter tubing dragging on the floor. On 5/29/24 at 11:01 AM, V2 (Director of Nursing) stated the catheter tubing should not be on the floor for infection control. V2 stated there would also be a chance that the tubing would get pulled out. The Face Sheet dated 5/29/24 for R434 showed medical diagnoses including chronic obstructive pulmonary disease, atherosclerosis, sick sinus syndrome, hypertension, hypercholesterolemia, and right femur fracture. The Nurse Practitioner's Note dated 5/28/24 for R434 showed additional diagnoses including dementia with other behavioral disturbance, mitral regurgitation, paroxysmal atrial fibrillation, and stage 3 chronic kidney disease. R434 has in indwelling urinary catheter in place. De-catheterization trial scheduled at the facility on 6/4/24 however patient is constantly pulling at catheter especially overnight. The Physician Orders dated 5/29/24 for R434 showed, indwelling catheter change, change bag with catheter. The Care Plan dated 5/18/24 for R434 showed, R434 is on enhanced barrier precaution due to presence of indwelling urinary catheter. Ensure that gown and gloves are used during high-contact resident care activities R434's care plan did not have any other catheter concern in place or interventions. The Admission Summary dated 5/18/24 for R434 showed Resident presented with a surgical incision to the right hip and catheter size 16 French. Resident post hip repair surgery. Resident alert and oriented x 1 (to person), calm, and cooperative. The facility's Indwelling Catheter policy (7/28/23) did not show any procedure related to keeping the catheter tubing from dragging or laying on the floor.

Based on observation, interview, and record review the facility failed to ensure a resident took their medications. This applies to 1 of 1 resident (R79) reviewed for medication administration in the sample of 28. The findings include: R79's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis, neurocognitive disorder with Lewy bodies, dementia without behavioral disturbance, hypertension, chronic kidney disease, cardiac arrhythmia, and anxiety disorder. R79's facility assessment 4/19/24 showed she has moderate cognitive impairment. R79's current Physician Order Sheet showed an order for Telmisartan 40 MG, Give 1 tablet by mouth two times a day for hypertension . On 5/28/24 at 10:50 AM, R79 was in her room sitting on her bed. R1 had a medication cup on her bedside table that had a white pill in it. There were powdery pill fragments in the cup as well. R79 said, I had a bunch of pills, this is the only one left. There were two white ones, I had one that was broken, and I need to know which one I swallowed. I need a nurse to come talk to me. On 5/28/24 at 11:00 AM, V10 (Registered Nurse) came and retrieved the pill cup. V10 said, This isn't from me. This might be from night shift nurse because I stay and watch her take them 1 by 1 to make sure she takes them. V10 looked through R79's medications in the nursing medication cart and determined the pill that was left in R79's medication cup was Telmisartan 40 mg (a blood pressure medication). V10 said R79's Telmisartan is scheduled twice a day, once in the morning and once in the evening. On 5/30/24 at 11:04 AM, V2 (Director of Nursing), I would expect the nurses to stay with the resident while they take their medications to make sure they take them all. The facility's policy and procedure with revision date of 7/28/23 showed, Medication Pass . Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures .

Based on observation, interview, and record review the facility failed to ensure a resident's soup was nectar thick for 1 of 4 residents (R68) reviewed for thickened liquids in the sample of 28. The findings include: On 5/29/24 at 11:38 AM, R68 was sitting in his wheelchair at the dining room table and V6 CNA (Certified Nursing Assistant) put R68's tray in front of him and removed the lids to his food and soup. V6 walked away and R68 began feeding himself. R68 had garden vegetable soup in a coffee cup that appeared to be a thin liquid. At 11:49 AM, V6 was asked to check R68's soup. The thickener was at the bottom of the coffee cup and not mixed into the soup to make it nectar thick. V6 stirred the soup, and it did not become nectar thick. V6 stated he had additional thickener available, went and got the thickener and added more to R68's soup. V6 stated he did not know why R68 was on nectar thick liquids. R68 was asked if he knew why he had thickened liquids and he stated, Because I eat a lot. R68 was asked if he had any problems swallowing and he stated, No. The meal ticket dated 5/29/24 for lunch on R68's tray showed he is on a regular diet, chopped with ground meat, and nectar thick liquids. The meal ticket showed he was supposed to have nectar thick garden vegetable soup. On 5/29/24 at 2:23 PM, V7 (Registered Dietician) stated R68 was on the nectar thick liquids because he is not swallowing properly. V7 stated V8 (Speech Therapist) had upgraded R68's liquids and then downgraded them. R68 stated she thought because R68 is cognitively impaired he is holding his food and not swallowing properly. V8 probably noted a cough when he was swallowing. Because of cognitive issues R68 needs maximum cues and has dysphagia. R68 is at his maximum potential; a mechanical soft nectar thick diet is his desired diet. R68 was put on the diet to prevent aspiration. The facility's Face Sheet dated 5/29/24 for R68 showed medical diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's disease, gastro-esophageal reflux disease, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and atherosclerotic heart disease. The Physician Order Review Report dated 5/29/24 for R68 showed a diet order entered on 4/19/24 for mechanical soft chopped with ground meat texture and nectar thick liquids. R68's Care Plan dated 4/16/24 showed he is at risk for alteration in nutritional status. A general pureed diet with nectar thick liquids was on his care plan on 4/11/24. R68's diet on his care plan was changed as follows: 4/13/24 - ground; 4/15 - chopped; 4/12 - thin liquids. R68's care plan was not updated on or after 4/19 to show he is on nectar thick liquids. The Speech Therapy Evaluation and Plan of Treatment dated 5/20/24 for services from 4/12/24 - 5/10/24 and 5/15/24 - 5/20/24 for R68 showed diagnoses including dysphagia, neurocognitive disorder with Lewy bodies, and cognitive communication deficit. Clinical Impressions: Patient appears slightly below cognitive baseline and with moderate oral-pharyngeal dysphagia. Speech therapy warranted to determine safest and least restrictive diet and return to prior level of function. Patient will tolerate the safest and least restrictive diet . mechanical soft, chopped, and nectar thick liquids. The facility's Dysphagia and Aspiration Clinical Guidelines policy (7/17/23) showed, Downgrading diet consistency (for example, from thin to thickened liquids or mechanical soft to pureed) will only occur after a review and discussion with the physician and consideration of all relevant factors. If it is decided that alterations in food of fluid consistency are indicated, the physician and/or staff will document why such alterations are right for the resident given the various risks and relevant factors involved for that individual and show that pertinent medical conditions or medication side effects have been considered. The staff and physician will identify individuals whose swallowing capabilities decline, fluctuate, or result in clinically significant complications and will adjust diet and food consistency where relevant and make the appropriate interventions.

Based on observation, interview and record review the facility failed to ensure a resident with an [MEDICATION(S)] pain pump followed up with the pain clinic to ensure the pain pump was filled on time. This failure resulted in resident being admitted to the ER with narcotic withdrawal symptoms including uncontrolled, sharp, constant hip sciatica pain and generalized body pain with nausea. This applies to 1 of 28 (R64) residents reviewed for pain in the sample of 28. The findings include: On August 15, 2022 at 2:02 PM, R64 was in her room. She stated she was in the hospital a month ago because of her pain pump. She had withdrawal symptoms because her pain pump wasn't filled on time, and they sent her out to the hospital. She stated her hip bone is wrapped around her sciatic nerve causing her pain. R64's electronic medical record (EMR) lists her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R64's order summary report for active orders as of June 1, 2022 shows, Patient has [MEDICATION(S)] pain pump: [MEDICATION(S)] 5000 mcg (micrograms)/ml (milliliters) and [MEDICATION(S)] 20 mg/ml current rate 1.975 mg/day. She also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R64's local hospital department of anesthesiology, critical care & pain medicine notes dated May 9, 2022 shows, Initial new patient evaluation, Chief complaint: patient presents with pain: whole body: consultation: pain pump refill. History of present illness: [AGE] year-old female with [MEDICATION(S)] (IT) pump moved here from ATL (Atlanta, Georgia). Per note from pain APN (advanced practice nurse) last month (post discharge emergency department (ED) instructions): . Primary team asking to check status of IT pump. Call placed to pain physician in Atlanta who has been managing her IT pump and spoke with Registered Nurse (RN) who verified pump medications and settings. Last refill March 24, 2022, Next alarm date is May 11, 2022. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Spoke with patient's care coordinator who states that she has been in contact with V13 local pain management physician's office who will be taking over pain management and management of the patient's IT pump locally. She (V13) will follow up with their office today to ensure that patient is seen in the next 3 weeks, prior to next refill date of May 11, 2022. Assessment: 1. presence of [MEDICATION(S)] pump, 2. chronic pain syndrome, [AGE] year-old female who is here due to mix-up with post ED discharge instructions, caregiver was told to follow up with our pain center in the paperwork and thus did not follow up with V13 local pain management physician as documented above in HPI. We had a discussion about the situation and agreed upon the below course of action. Referrals: follow up with V13 local pain management physician for IT pump management, will do a 1x refill of pump so she doesn't run out on May 11, 2022 and go into withdrawal but we discussed that our practice will not be taking over IT pump management for her going forward and per chart review patient was to follow up with V13 local pain management who reportedly accepted taking over management of this pump and patient. Note from Registered Nurse: patient in clinic to see doctor today, plan for refill pump on May 11, 2022. Alarm date May 11, 2022. Pump medication ordered and to be delivered May 10, 2022. On May 11, 2022, R64 returned to the same doctor and had her 1x pump refill as discussed above. The pump changes were printed, and the patient was instructed to follow up with V13 local pain management physician. R64's EMR does not show another appointment for her pain pump. R64's progress notes dated June 30, 2022 shows, SW (V11 social worker) received a call from patient who stated she needed to speak with SW. Per patient, she (R64) states her pain pump is due for a refill. SW was able to locate the name and location of the place she got the refill last time. SW notified charge nurse to follow up on next refill due date. According to charge RN, R64's pump is good through August 17, 2022. SW relayed this information to R64, who states that she does not believe this to be true, and R64 states that local pain clinic nurse told her it was due June 28, 2022. This SW placed a call to local pain clinic nurse to follow up and get more information on the conflicting dates. Local pain clinic nurse was not available at the moment, per scheduler, and a message was left with priority to return SW's call. R64 appears anxious, she states she is worried that the pain pump will run out and she will not be able to tolerate the pain if she runs out. SW assured R64 that the nursing staff is aware, and the team is actively working on finding a solution to this problem . R64's progress notes dated June 30, 2022 shows, SW received a call back from local pain clinic nurse, who confirmed that patient's pain pump was due on June 28, 2022. Local pain clinic nurse states they made an appointment at 10:20 AM on July 5, 2022 for the pump refill. Local pain clinic nurse advised for patient to report to local emergency room (ER) for possible ICU (intensive care unit) admission due to withdrawal symptoms in the meantime. SW then went to R64's room again to inform her of the plan of care. R64 was on the phone with local pain clinic nurse at that time, and based on R64's symptoms, R64 recommended R64 go to local ER for possible admission. SW connected local pain clinic nurse and the charge nurse to relay orders. R64 aware that she will be sent out to local ER . R64's progress notes dated June 30, 2022 shows, SW informed/handed over the phone to this writer (Registered Nurse at the facility) to talk to the local pain clinic nurse. Local pain clinic nurse reported that patients pain pump ([MEDICATION(S)]/[MEDICATION(S)]) was due to refill on June 28, 2022. Per medical doctor/local pain clinic nurse reported that patient is having withdrawal symptoms like nausea/vomiting, patient reported that she not feeling good and instructed this writer to send patient to local ER for admission to ICU . R64's progress notes dated June 30, 2022 shows, follow up at local ER, spoke to nurse, reported that patient will be admitted for narcotic withdrawal and generalized weakness. The local hospital documentation for R64 shows, Anesthesia Pain Service Consultation Note Dated July 1, 2022, Chief complaint: uncontrolled pain. HPI (history of present illness): R64, known to us from previous admission, is a [AGE] year-old female with a PMH (past medical history) of . chronic back pain with IT pump, who recently moved to IL (Illinois) from Atlanta, Georgia in April 2022, who presents with nausea, vomiting, headache concern for withdrawing since her pump ran out. Patient had a one-time emergency pump refill on May 11, 2022 so she won't go into withdrawal, and was supposed to follow up with V13 local pain management physician for a pump refill. Patient did not follow up or establish care with V13. Per chart reviewed, patient reached out to our outpatient pain clinic yesterday (June 30, 2022) because V13's office declined management of her pump since patient has a refill with our office. Patient's medical care has been coordinated by care coordinator who informed our service on April 15, 2022 that V13 agreed to take over management of patient's IT pump so I'm not sure why there is a disconnect but will discuss with her. Patient was not accepted to our clinic for pump management, but since her pump has been alarming and there was a concern for withdrawal, she was instructed to go to the ER. Patient reports uncontrolled hips, sciatica pain and generalized body pain with nausea, denies vomiting at this time. Denies headache. Describes pain as sharp and constant. Alert and oriented X 3, but very drowsy, falling asleep between sentences, need to shout to wake her up. States she thinks she is going through withdrawal because her pump ran out. Says she feels better this morning Plan: 3. interrogated IT pump, confirmed that patient's IT pump is empty. Discussed with attending's, will refill pump with saline to prevent pump failure & will manage patient's withdrawal symptom . On August 15, 2022 at 12:09 PM, V12 RN stated, she had tried to make an appointment for R64 at the pain clinic and originally made one for August 18, 2022 but she did not document that in R64's EMR. The nurses are responsible for making appointments for residents. R64's EMR showed no documentation in the EMR about an appointment for August 18, 2022 until after she was readmitted to the facility from her hospital stay on June 30, 2022. R64's minimum data set (MDS) dated [DATE] shows she (R64) is cognitively intact. The facility's pain management policy not dated shows, Policy: To promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: promptly and accurately assessing and diagnosing pain, encouraging residents to self-report pain, aggressively assessing pain in non-verbal and cognitively impaired residents, increasing comfort and reducing depression and anxiety of daily living, monitoring treatment efficacy and side effects, preventing and minimizing anticipated pain when possible, using non-pharmacological, using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences.

Based on observation, interview and record review the facility failed to ensure staff followed Centers for Disease Control and Prevention (CDC) recommendations by not wearing gowns and an N95 mask when testing residents for COVID-19 and not performing hand hygiene in between resident test. The facility failed to ensure staff wore a N95 mask for residents on contact/droplet precautions to rule out COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 125 residents residing in the facility. The facility staff failed to apply appropriate PPE when entering room of a resident on contact isolation (R38). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/10/21 when V4 (Contracted laboratory staff) were testing residents for COVID-19 without wearing a gown or N95 mask. The Immediate Jeopardy was identified on 5/10/21. V1 (Administrator) was informed of the Immediate Jeopardy on 5/11/21. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 5/12/21; however, noncompliance remains at a Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's room/bed list provided on 5/10/21 shows, there are 125 residents residing in the facility. The facility's resident COVID-19 vaccine record provided on 5/10/21 shows, 78% of the residents are vaccinated for COVID-19. The facility's employee COVID-19 vaccine record provided on 5/10/21 shows, 68% of the staff are vaccinated for COVID-19. The facility's quarantine list provided on 5/10/21 shows 6 residents (R64, R66, R155, R159, R160, and R161) are on droplet/contact precautions to rule out of COVID-19. The roster provided by the facility shows these residents are not vaccinated. 1. On 5/10/21 at 9:36 AM, V4 and V5 both (Contracted laboratory staff) were testing residents on the XXX unit for COVID-19. V4 was doing the actual testing of residents while V5 was doing the paperwork for the testing. V4 was wearing a KN95 mask and did not have a gown on. V5 was wearing a surgical mask with a KN95 over it. V4 went into R50 and R28's room to test both residents. He tested R50 and walked out of the room, handed the test tube with the swab to V4 and went back in and tested R28. He was not wearing a gown or washing his hands in between testing. On 5/10/21 at 10:20 AM, V4 (Contracted laboratory staff) entered R37's room without a gown on and swabbed R37 for COVID-19. V4 exited R37's room, removed his gloves but did not wash his hands or hand sanitize. On 5/10/21 at 10:25 AM, V4 entered R9's room and donned his gloves but did not put on a gown and swabbed R9 for COVID-19. On 5/10/21 at 10:36 AM, V2 (DON) said when testing residents for COVID staff should wear a KN95 mask, gown, gloves, and face shield. The facility's COVID Testing undated Policy states NP or trained RN to obtain NP swab and wear required PPE for testing (N95, goggles/face shield, gown and gloves) remove gloves and perform hand hygiene between each HCP test . The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated 2/23/21 shows, Collection of Diagnostic Respiratory Specimens: When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) from a patient with possible [CONDITION(S)]-CoV-2 infection, the following should occur: Specimen collection should be performed in a normal examination room with the door closed. HCP in the room should wear an N95 or equivalent or higher-level respirator, eye protection, gloves, and a gown. Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below. 2. On 5/10/21 during initial tour, V7 (LPN), V8 (RN), V9-V12 (All CNA's) were wearing KN95 masks. R64, R66, R155, R159, R160, R161, R356 were all on contact/droplet precautions to rule out COVID-19. On 5/10/21 at 11:20 AM, V6 (Housekeeping) was on the first-floor cleaning rooms. She had a surgical mask on under her KN95 mask. She said the staff told her to wear it this way. On 5/10/21 at 11:16 AM, V7 (LPN) was wearing a kn95 mask. V7 said residents who are admitted from the hospital are placed on quarantine contact/droplet precautions. V7 said staff should wear a gown, gloves, kn95 mask and face shield for quarantine. V7 said he has been working for the facility for about one year and has not been fit tested for a N95 mask and does not have a N95 mask. On 5/10/21 at 10:36 AM, V2 (DON) said new admissions are placed on quarantine droplet/contact isolation to rule out COVID-19. V2 said right now we have primarily KN95 mask for staff; that's how we have been doing it. V2 confirmed they are not in crisis capacity for PPE usage. Staff have been fit tested for N95 mask since November or December. They are not done fit testing all staff. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic last updated 2/23/21 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The CDC use of personal protective equipment (PPE) when caring for resident with confirmed or suspected COVID-19 shows, Preferred PPE- Use N95 or higher respirator (both straps attached to the person's head), face shield or googles, gloves, and isolation gown. The facility has these signs taped up on the walls randomly around the facility. The Immediate Jeopardy that began on 5/10/21 and the immediacy was removed on 5/12/21 when the facility took the following actions to remove immediacy and correct the non-compliance: 1. On 5/10/2021 on-going education to all staff/all shift in-service was initiated regarding proper PPE use, including donning a N95 and eye protection as well as a review of isolation precautions. In-services were conducted by nursing supervisors and department heads and will continue on through 5/16/21 until all staff receive the re-education. 2. Effective 5/12/2021, all department heads will check their respective departments daily at the start of each shift for proper PPE usage as well as provide infection control in servicing. This will continue until substantial compliance is determined by the department. 3. The DON or ADON will meet with lab staff at the start of their shift on the facility testing days to insure their continued understanding and compliance regarding proper PPE use/isolation precautions. 4. The facility began N95 fit testing on 12/11/2020 and this process is on-going. As of 5/11/2021, 86 staff members remain to be fitted. The fit testing is conducted by RT and RN's. The Human Resource Director began contacting the 86 remaining staff members at 4pm on 5/11/2021 to advise them of their fit testing schedule and that anyone not tested will be prohibited from working until this is complete. The target completion date for fit testing is 5/24/21. All new hires will be required to be fit tested prior to start date effective 5/11/2021. 5. The ADON or Designee will conduct a 3-month weekly audit of staff/vendors to ensure compliance with proper use of PPE and isolation precautions. 6. On 5/11/2021 at 6pm, all vendors were sent a correspondence regarding proper use of PPE and isolation precaution awareness/compliance required at the facility. 7. Current infection control policies will be updated to reflect all current CDC and state regulations/guidance. 8. The facility QAPI plan will be reviewed and revised in the areas related to infection control and proper PPE usage. 3. R38's face sheet shows she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's current care plan shows she is on contact isolation for VRE (Vancomycin-resistant Enterococcus) an infection in her wound. R38's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021 outside of R38's room there was a sign posted showing she was on contact isolation and gown and gloves should be worn when entering her room. There was an isolation cart outside of her room that contained disposable gowns and gloves. On 5/10/2021 at 1:37 PM, V25 (Registered Nurse/RN) entered R38's room without putting on a gown or gloves. He went over beside R38's bed and was talking to her while leaning on the over bed table. R38 exited the room at 1:44 PM. The surveyor asked what PPE (Personal Protective Equipment) was required to enter R38's room he responded that he did not put a gown and gloves on because he was only talking to her. V25 also said he cannot remember why R38 is on contact isolation because it is hard to keep track of 30 residents. On 5/10/2021 at 1:45 PM, V24 (CNA) entered R38's room and did not apply a gown or gloves. When the surveyor asked R38 why she did not apply a gown she responded, I am just taking her off the bed pan. On 5/12/2021 at 9:11 AM, V2 (Director of Nursing) said that the expectation for any resident on contact isolation is that a gown and gloves should be worn by staff when entering the residents room.

Based on observation, interview and record review, the facility failed to do a complete skin assessment for one resident on admission. The facility failed to identify a pressure ulcer before it became unstageable. These failures resulted in R7 developing a painful, infected unstageable pressure ulcer requiring antibiotics and a wound vac (negative pressure wound therapy) for treatment and needing an extended stay (July 16, 2015 to August 13, 2015) at the facility. This applies to 1 of 2 residents (R7) reviewed for pressure ulcers in the sample of 24. The findings include: R7's Minimum Data Set (MDS) dated [DATE] shows an admitted [DATE]. R7 is cognitively intact, requires extensive assistance of two plus persons for toileting and is occasionally incontinent of bowel and bladder. R7's is 62 inches tall and weighs 202 pounds. The MDS shows she is at risk for developing pressure ulcers. R7's hospital transfer records dated May 30, 2015 show that she had back surgery on May 27, 2015 with an incision to her lower midline back with steri-strips applied. On August 11, 2015 at 12:10 PM, R7 was laying in bed. R7 pulled her pants down and turned on her left side to prepare for a dressing change. When R7 was on her side, no dressing was visible. E4 (Physical Therapist) spread R7's buttocks apart, removed a dressing from the sacral area and a 0.3 cm (centimeters) by 0.3 cm pressure ulcer was present. On August 12, 2015 at 9:45 AM, R7 said that she first noticed that she had something wrong with her bottom when they transferred her from the hospital to the facility. R7 said that when the ambulance transfer company first came to get her, they brought something that she had to sit upright on and she could not do this due to pain in her buttocks. They had to return with a stretcher so she could lie down. She also stated, When I got here I was complaining about not being able to sit. They were giving me pain meds. When I was complaining of pain, they probably thought it was from my back surgery. R7 said that one day she was complaining of the pain again. They checked her buttocks and found the pressure ulcer. R7's Comprehensive Nursing Admission assessment dated [DATE] shows an admitting [DIAGNOSES REDACTED]. Under the heading skin, there was no description of any wound (including her surgical wound). R7's Nursing Notes dated June 3, 2015 shows, Pt. (patient) noted with redness, excoriation along butt crack. Wound nurse notified. The June 7, 2015 Nursing Notes show, patient has a very sensitive red buttocks. The June 8, 2015 Nursing Notes from E3 (Wound Nurse) shows, Assessment to buttocks area shows some moisture related denuded skin at bilateral buttocks/rectal area. Also noted at pre sacral area (which is difficult to see unless buttock cheeks are spread apart) was an unstageable ulcer with some redness and warmth to peri wound area. The June 12, 2015 Nursing Notes show, P.T. (Physical Therapist) reports more depth and foul odor while doing dressing change to sacral wound. Pt. (patient) also reports more pain to the area. MD made aware and ordered [MEDICATION NAME] (antibiotic) for 7 days. The June 19, 2015 Nursing notes show, [MEDICATION NAME] given for c/o (complaints of) buttocks pain. On August 12, 2015 at 11:20 AM, E3 (Wound Nurse) said that on June 8, 2015 she went in to see the excoriation to R7's buttocks that had been reported to her by the nurse. When she went in to look at the excoriation, something made me open the crack up more and that is when I could see the unstageable ulcer. E3 also stated, It was not visible to the naked eye unless you spread her butt cheeks way open. E3 said that when skin checks are performed, she uses a mirror and will look at every area of the body. She would have looked in the crease of her buttocks if she was doing a skin check. E3 said that R7's wound probably started as a deep tissue injury due to her history of sitting in a chair for over 30 days. E3 said a deep tissue injury is purple or maroon in color, non-blanchable and located over a bony prominence. E3 said that R7 would have had signs of a deep tissue injury at least 3-4 days prior to developing an unstageable pressure ulcer. E3 also said that if a resident is found with a deep tissue injury, treatment would be started right away. Treatment would include: protecting it with a foam dressing, starting ultrasound therapy, getting an air mattress, and dietary would be notified for a consult. E3 stated, It really does help. R7 ' s Electronic physician's order [REDACTED]. R7's Electronic physician's orders [REDACTED]. R7's Wound Care Addendum form dated June 8, 2015 shows an unstageable pressure ulcer on the pre sacral area/cleft measuring 4.5 cm by 1.8 cm. The wound was 100% (percent) black eschar (dead tissue) with 3 cm of red/warm surrounding tissue. R7's Wound Care Addendum notes dated June 29, 2015 shows a stage III pressure ulcer measuring 4.5 cm by 2 cm by 1.5 cm with 10% slough and 90% granulation tissue. R7's Braden Scale (Pressure ulcer risk scale) dated June 8, 2015 shows that she is at mild risk for the development of a pressure ulcer. R7's Medication Administration Record [REDACTED]. Location is not noted. The Medication Administration Record [REDACTED]. Location is not noted. On June 19, 2015, the Medication Administration Record [REDACTED]. R7's Plan of Care dated June 1, 2015 states that she was admitted to the facility for rehab. R7's Plan of Care for pressure ulcers and skin integrity shows an intervention with an effective date of June 3, 2015 that, Skin will be checked during routine care on daily basis and during bath or shower. Concerns to be conveyed to Nurse. R7's Care Plan for pressure ulcers also shows an intervention with an effective date of June 8, 2015 that, Skin assessment form to be done upon admission and quarterly. R7's undated Physical Therapy Discharge summary shows that on July 10, 2015 R7 stated, My doctor wants me to stay until my wound is all closed up. It just takes so long. The summary also states that R7 was discharged from mobility Physical therapy on July 16, 2015. On August 12, 2015 at 12:10 PM, Z1 (Advanced Practice Nurse) said that R7's focus was on her back incision and not her buttocks. Z1 was unsure on how long R7 had had the pressure ulcer. Z1 said that the doctor started her on antibiotics for a possible infection due to the wound having an odor. The odor cleared up after receiving the antibiotics. Z1 also said R7 had to stay at the facility until her pressure ulcer healed. Z1 stated, Just because no one looked, doesn't mean it wasn't there. They didn't look because that was not the issue. On August 12, 2015 at 12:00 PM, E2 (Director of Nursing) stated, On my low risk for pressure ulcer residents, I don't expect them (nurses) to look in every nook and cranny. They usually just eyeball it. At 2:00 PM, E2 said R7 was not identified as a person who's nooks and crannies needed to be assessed. E2 stated, When they (residents) come in, we don't look in the crack of a high functioning resident. The facility's undated Admission of a Resident policy shows, Observe the condition of skin and scalp. Note any abnormalities of hair or skin (i.e.,[MEDICAL CONDITION], pressure sores, dryness, surgical scars, dyspnea, diaphoresis, etc.) The facility's undated skin care protocol shows, Resident will be assessed upon admission and at least quarterly. For low and mild risk, residents will be assessed quarterly or as needed. On bath/shower days, resident will be observed for signs of redness.